In Resolution 19/37 adopted on March 23, 2012, the Human Rights Council decided to focus its next full-day meeting in 2013 on the right of children to enjoy the highest attainable standards of health and invited the Office of the High Commissioner for Human Rights (OHCHR) to prepare a report on this issue. OHCHR requested various stakeholders, including governments, UN agencies, and civil society organizations to provide input for the report, focusing on children’s main health challenges, barriers to the implementation of children’s right to health, and examples of good practice. This column is based on a paper that I developed and submitted on October 1, 2012 to OHCHR on behalf of the NGO Committee on Children’s Rights and the Psychology Coalition at UN Headquarters in New York City.

Today across the world children are being exposed to high levels of stress from various (and frequently multiple) debilitating conditions including: poverty resulting in chronic hunger, malnutrition, and preventable diseases; disparities in their access to physical and mental health care; disparities in their access to and attainment of primary and secondary levels of formal education; abuse and exploitation, including trafficking and sexual exploitation; violence against children in the family, the community, and in armed conflict; hazardous and injurious child labor; harmful traditional practices like early marriages and genital cutting of girls; loss of parental or family care due to death of parents during war, natural disasters, diseases like HIV/AIDS, and separation during migration.

While certain levels of stress are necessary for survival, according to the Academy of American Pediatrics, children experience toxic levels of stress from “strong, frequent or prolonged activation of the body’s stress response systems in the absence of the buffering of a supportive, adult relationship (Shonkoff & Garner, 2012).” Children experience stressors as traumatic and toxic depending on their developmental stage; their previous life experiences and developmental capacities; the intensity, duration, and number of stressors to which they are exposed at the same time; and their access to family or other caring adults who have the capacities and resources to respond effectively to children’s needs (Gunnar, Herrera, & Hostinar, 2009).

Effects of Toxic Levels of Stress. The adverse relationship between stress and children’s development has long been established by psychological research (Garmezy & Rutter, 1983; McLoyd, 1990), but the physiological mechanisms underlying this relationship have only recently begun to be uncovered by scientific studies. When stressors like persistent hunger and poverty threaten a child, hormones are released and distributed throughout the child’s body. Severe and persistent exposure to stress hormones can disrupt the connection of brain circuits and result in the development of a smaller brain. Brain circuits are particularly vulnerable when they are developing during infancy and early childhood, causing children to develop a low threshold for stress, thereby becoming overly reactive emotionally to stressors in later childhood (Gunnar, Herrere & Hostinar, 2009; Shonkoff & Garner, 2012; Teicher, Anderson & Polcan, 2012). Research has demonstrated further that high levels of stress hormones, including cortisol, result in suppression of the immune response, leaving the child vulnerable to infections and chronic health problems (Shonkoff & Garner, 2012). Persistently high cortisol levels can damage the hippocampus (14), a brain area responsible for learning and memory, resulting in childhood cognitive deficits (American Psychological Association, 2012).

Scientific findings also suggest that, in the absence of sensitive, attentive and resourceful adult support, there are long-term consequences of exposure to toxic stress and that adverse childhood experiences may have mental and physical health consequences that last into adulthood (Middlebrooks & Audage, 2008; Shonkoff & Garner, 2012; Szalavitz, 2012). These include: increased risk of cardiovascular disease, depression, anxiety, suicide attempts, substance abuse, and post-traumatic stress disorder (Gunnar, Herrere & Hostinar, 2009). It is therefore imperative that, as a world community, we advocate with governments for the prevention and amelioration of toxic stress by establishing healthy and safe environmental conditions for children, families, and their communities.

Children’s Rights to Physical and Mental Health and Well Being. The Convention on the Rights of the Child (CRC) is the most widely accepted human rights standard, having been ratified by most nations of the world, except the United States, Somalia, and South Sudan. The CRC provides for the protection and fulfillment of the broad range of economic, civil, political, and cultural rights, including children’s rights to survival, security, development and participation (Convention on the Rights of the Child, 1989). It calls for governments that have ratified it to “recognize the right of every child to benefit from social security (Article 26)” and “a standard of living adequate for the child’s physical, mental, spiritual, moral and social development (Article 27).” These rights apply to all children without discrimination of any kind, regardless of the child or the child’s “parents or legal guardian’s race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status (Article 2).” The preamble to the Convention recognizes that “in all countries in the world, there are children living in exceptionally difficult (stressful) conditions and that such children need special consideration. For example, special articles cover refugees and migrants (Article 22), children who are physically and mentally challenged (Article 23), children living under traditional practices injurious to their health (Article 24), under trafficking (Optional Protocol to the CRC on the Sale of Children, Child Prostitution and Child Pornography, 2002), and under armed conflict (Optional Protocol to the CRC on the Involvement of Children in Armed Conflict, 2002).

Consistent with psychological theory (Bronfenbrenner, 1986), the preamble and other articles of the CRC recognize that the family is the natural environment for the growth and well-being of its members, particularly children. As such the family is to be given the necessary protection and assistance to assume its responsibilities, so that the child may grow up in an atmosphere of “happiness, love, and understanding” (Convention on the Rights of the Child, 1989).

Barriers in Implementing Children’s Rights to Health. Although the CRC is the most widely ratified human rights treaty, governments in all regions of the world have not carried out their commitments to implementing its principles by investing in childhood, particularly early childhood, as the foundation for healthy human development. A recent study of child well-being in 28 countries in the Organization for Economic Cooperation and Development found that only 24% of childhood expenditures were allocated to the period from birth to age 5, while 36 % was spent on children age 6-11, and 41% from age 12 to 17 years. While the investment in early childhood is comparatively low in these countries, it is significantly lower in sub-Saharan Africa, which also has the highest poverty rate for children in the world (Shonkoff, Richter, van der Gaag & Bhutta, 2012).

In most countries of the world, including the developed regions, many children and their families continue to live in poverty reflected in stark disparities in employment in decent jobs, education, physical health, mental health, and access to quality health care and social services. Especially in developing countries, transportation to the nearest medical facility is often at a distance. There is an even greater scarcity of quality and affordable mental health care, therefore children often do not receive care. Families are often not literate in the language of health care facilities further reducing the accessibility of healthcare and adherence to treatments. Many communities do not have access to trained medical and mental health staff. Moreover, staff that may be available lack multicultural competencies and sensitivity, making it difficult for providers to work with the range of diverse families in the best interest of their children.

Recommendations Offered to OHCHR to Promote, Protect, and Fulfill Children’s Right to Quality Physical Health, Mental Health and Psychosocial Well-being

The CRC calls on governments to establish social programs to provide necessary support for children and those who care for them. We urged governments and the international community to implement the Social Protection Floor Initiative, including access to physical and mental health care, to take care of basic human needs of all vulnerable groups.

Since research has established that the architecture of the brain (which is the foundation for all aspects of health) begins before birth and continues throughout the early years into later childhood, we urged governments to wisely invest significantly more resources, and especially to front-load science-based investments in support of infant and early childhood physical and mental health development, in order to increase the survival of children born under adverse conditions and to improve the life outcomes of those children who survive infancy (The Urban Child Institute, 2012).

Physical and mental health and cognitive, emotional, and social aspects of children’s development are all interrelated. Therefore, physical and mental health should be integrated to support child development and life-long holistic health. Governments should provide resources and trained staff to offer mental healthcare within primary health care. They should make effective use of available resources by providing accessible multidisciplinary social service centers (mobile vans in some areas) to provide one-stop services, including physical and mental health care, especially in rural areas, with literacy, continuing education, and entrepreneurial training for parents and families in these centers.

We urged governments to provide trained psychologists and mental health counselors, well versed in culturally-specific methodology and techniques, to train and work with local community health workers, especially in rural areas, to recognize mental health problems of children and to provide services and referrals in an informed, nondiscriminatory manner.

A promising practice is the training of Community Health Workers to provide care for children and families within the context of homes in local communities. Community Health Workers come from the community and can better understand the needs of their members. They share the culture and language and can be trained by medical and mental health staff to provide care for children and families, in cases where it would be inconvenient or impossible for care to be provided through a local clinic or hospital (Nabudere, Asiimwe & Mijumbi, 2012; Valen, Naravan & Wedeking, 2012). While the ideal situation is for children and families to have access to high quality integrated medical and mental healthcare, effectively trained and monitored community health workers can fill the gap when such care is not immediately available.

Since sensitive, responsive caregiving can buffer and protect children from the long-term physical and mental health consequences of toxic stress, governments should provide parents and early childhood caregivers with expert assistance and education on how to manage severe stresses and skills to help children who exhibit symptoms of abnormal responses to stress before these produce pathology.

The long-term negative effects of toxic stress may be reversed to the degree that timely economic, educational, and psychological support is provided for children and their families. We urged government to provide specialized interventions and adequate and appropriate services for girls and boys who have been trafficked and involved in armed conflict, hazardous labor, or sexual exploitation, in order to address their physical, psychological, social, and educational needs, including reintegration into their families, schools, and communities.

As children grow into adolescents and adults, they will face both predictable and unpredictable stressors. Therefore, it is important for governments to provide stress inoculation or stress management training for children to enhance their capacities to cope effectively with stress, by lowering the reactivity of their stress responsive neurobiological and neuroendocrine systems to stress they may experience in their later years. This training can be integrated into physical and mental health components of the formal educational curriculum of schools.

Governments need to increase the availability of assessment and treatment for children with serious stress-induced physical and mental health problems.

Governments should promote ongoing human rights learning for all members of society, including children and families living in poverty and other adverse conditions, to foster their physical and mental vitality, resilience and activism to alleviate toxic stressors and to advocate for positive physical and mental health changes in their own lives and the lives of others.

References

American Psychological Association. (2012). Effects of poverty, hunger and homelessness on children and youth. www.apa.org/pi/families/poverty.

Bronfenbrenner, U. (1986). Ecology of the family as a context for human development. Developmental Psychology, 22(6), 723-742.